Use of Interactive Metronome Interventions within
the diverse population of pediatrics.
CONGRATULATIONS!
• You have completed
the IM Certification
process.
• You have gained an
understanding of how
IM can help a diverse
population.
• Get ready to learn
more advanced
applications of IM.
Applying Interactive Metronome
to the World of Pediatrics
diverse
energetic
variety
irrational
stimulating
unpredictable
creative
novel
aggressive
clumsy
unforgiving
stubborn
defiant
ritualistic
disorganized
Common Q&A Leading up to the
Development of PBP
• At what age can I begin to implement IM
with a child?
• What can I do to motivate a child to do IM?
• How long should IM sessions be with a
child?
• Can I use Listening Therapy at the same
time as IM?
• What should I do if a child begins to cry as
he doesn’t like IM?
Common Q&A Leading up to the
Development of PBP
• Will IM help my child get off ADHD
medications?
• How can I get my child to sit still for long
enough to do IM?
• Can a child with a cochlear implant use IM?
• How can I use IM to improve ocular-motor
stability?
• Can I use IM in a group setting?
And thus, the concept of getting IM
training ‘IN SYNCH’ with the needs of
pediatric providers was born…
Brainstorm 1: Who, What &
Where do you IM?
1. What is the youngest child you have ever used IM
with?
2. Where do you typically treat your IM clients?
3. What key problems do your clients present with?
Give 3 examples
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3.
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4. List any secondary problems that you have
identified while using IM.
5. What clients have NOT benefited from IM? Why
do you think this was the case?
Areas Commonly Identified for
Treatment
PHYSICAL
• Tone
• Range of movement
• Endurance
• Gross motor coordination
• Fine motor coordination
• Reflex integration
• Posture
• Environmental limitations
• Vision impaired
• Hearing impaired
• Sensory-motor impairments
Areas Commonly Identified for
Treatment
COGNITIVE LINGUISTIC
• Learning disabilities
• Delayed processing
• Auditory processing delays
• Language processing delays
• Memory impairments
• Attention to task
• Organizational skills
• Poor insight/judgment
• Decision-making skills
• Following directions
• Delayed working memory
• Poor sequencing
• Ability to comprehend technology
Areas Commonly Identified for
Treatment
EMOTIONAL
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Anxiety
Self-esteem
Sense of self
Depression
Lability
Irrational fears
Attitude
Areas Commonly Identified for
Treatment
BEHAVIORAL
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Passive
Defiant
Aggressive
Controlling
Agitation
Self-obsessed
Ritualistic
Self-stimulating
Inability to attain/sustain
eye contact
Areas Commonly Identified for
Treatment
SENSORY
• Sensory-seeking
• Sensory-avoiding
• Visual sensitivities
• Tactile sensitivities
• Auditory sensitivities
• Olfactory sensitivities
• Gustatory sensitivities
• Vestibular sensitivities
• Body-in-space awareness
• Internal drive
• Impaired modulation skills
• Impaired behavioral regulation
• Inability to attain/sustain a ‘ready alert state’
Areas Commonly Identified for
Treatment
NEUROLOGICAL
• Developmental delays
– genetic
• Developmental delays
– environmental
• Developmental delays
– acquired
Maximum
Weightage with IM
(child led!)
Use of an X-Ray
Vest & Pinto Beans
to Give Deep
Pressure Input
IM Cave Providing Safe
Environment
Blending Oral Motor Sequencing Task
with Bilateral Upper Extremity Control
on a Hand Trigger
Head & Neck ROM to the Beat
Oral Motor - Tongue ROM
Chewing In Sync to the
Trigger & Beat
Strategies to Modify IM
• As your learning
foundations develop start thinking about
modifications to IM
that will facilitate
activity application to
specific patients.
IM student squishing bugs to a
consistent interactive beat.
Brainstorm 2 – How are you
using your IM?
1. List 3 activities that you feel blend well with IM
treatment activities.
2. What professional attributes do you bring to your
IM sessions that help enhance activities?
3. List 3 items that are useful to have on hand when
applying IM to the pediatric population.
4. What is your best advice to a co-worker when
using IM with the pediatric population?
5. What areas do you find most challenging when
using IM with the pediatric population?
Modifications – Environmental
As you set up your
treatment area for
each individual,
consider :
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Size of room/space
Seating options
Lighting options
Available wall space
Available floor space
Storage for small/large
items
Sample Pictures of IM Room with
Desktop Computer (Clinic Setting)
Desktop IM Set-up in a
Home Setting
Portable IM Unit with Use of
Rolling Carts
Portable IM Unit with Use of a
Rolling Computer Bag
Modifications – Applying IM to
Your Treatment Environment
Emily
• Emily is an 8 year old child with a diagnosis of
“handwriting difficulties.”
• She comes in for her regularly scheduled one-hour
OT session.
• She is working on
proximal stability (trunk control)
– bilateral coordination
– fine motor skills
– visual attention to task
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Treatment Sessions May
Include These Activities:
Treatment
Minutes
Reach and place activities while sitting on a therapy ball
10
Rolling across the treatment mats holding a ball overhead
5
Jumping-jacks, superman, pretzel rolls, dance and freeze games 10
IM exercises (B hands, R hand, L hand with reference tone)
15
Eye-tracking activities in supine with suspended ball
10
Fine motor activity (puzzles/ker-plunk/jenga)
10
Modifications – Applying IM to
Your treatment Environment
JOHN
• John is a 3 year old boy with a
diagnosis of developmental delays.
• Scheduled PT session of 30 minutes
duration.
• Fleeting attention, quick to quit.
• Goals include being able to:
- climb a flight of 5 stairs
- attain half-kneeling stance
- being able to pick up items from the floor
with stand-to-squat stance
- kick a ball with his right foot
Treatment Sessions May
Include These Activities:
Treatment
Minutes
Crawling up an inverted wedge and crashing onto mats
2
Supported half-kneeling while hitting suspended ball
2
Throwing beanbags at target and picking them up in supported
squat-to-stand transitions
2
Kicking playground ball at bowling pins
2
IM in supported sitting with PT, hand-over-hand
2*
Repeat activity sequence up to 3 times.
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*As proficiency and tolerance to IM improves, start to increase the
minutes of IM used in each session.
Get in as many IM repetitions as you can while presenting the justright challenge.
Modifications – Sensory
Considerations
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Lighting
Space
Sounds
Surfaces
Scents
Modification Kit
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Colored Tape
Self-adhesive Velcro strips
Non-slip matting
Various textured/sized
balls
Visual timer
Balloons
Bubbles
Stickers
Washable tattoos
Munchies
Chewables
Suckables
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Variety of switches/triggers
Cable splitters
Portable speakers
Variety of headphones
Soft squishy bug toys
Selection of small kids toys
Silk scarves
Ball on a string
Flashlights
Word/Letter/Picture flash
cards
• Soft knit gloves
• Sanitizing hand wipes!
Larger Items to Consider
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Hopper or rebounder trampoline
Bosu
Balance disc
Therapy ball
Aeromat or large foam cushions
Weighted balls (3-5#)
Mop handles
Weighted items (i.e., vest, blanket, bean bags)
Portable sports equipment (i.e., baseball bat,
hockey stick, etc.)
• Portable floor mat
JAKE - Sample Goal Analysis
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“OT and Speech Therapy to
address difficulties with
handwriting and reading”
• Change to “Occupational
Therapy evaluation and treat,
Speech Therapy evaluation
and treat, diagnoses: lack of
coordination and
developmental language
delays.”
• 7 years of age, struggling with
academics, an active child,
below peer level
developmentally.
Difference in Learning Style
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Attention to task
Reading / writing skills
Disruptive influence on classmates
Gross and fine motor skills
Balance
Visual motor skills
Reflex integration
Language delays
Sensory-motor integration skills
Treatment Plan: OT and ST two times per week
PT referral
Developmental Optometry referral
Jake’s Goals
Within six months (5/08), Jake will:
1. hold a pencil with a right-handed
modified tripod grasp (85% of written
tasks).
2. trace infinity pattern independently with
consecutive intersections for 20 reps.
3. throw overhand 5ʼ at target with right upper
extremity 5/8 times.
4. demonstrate shoulder girdle strength sufficient to
wheelbarrow walk 30 with support at lower legs.
5. read 10 basic site words fluently.
6. follow 2-step verbal directions timely and accurately.
Brainstorm 3 – Consider Each
of the Six goals
Brainstorm the following aspects of each goal:
1. What skills are required for goal
attainment?
2. What activities/exercises could you use to
work toward achieving these goals?
3. List three modifications of the use of IM to
achieve goal attainment.
4. How could you set up these activities to
mask the challenge of the activity?
Goal #1
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Attention to task
Bilateral integration (praxis)
Gross and fine motor skills
Body-in-space awareness
(proprioception)
Kinesthesia (movement/motor
planning)
Sensory-processing skills
(visual/auditory/vestibular/
kinesthesia/proprioception)
Phonological awareness
Expressive/receptive language
Maneuvering colored balls
inside infinity loop to the
rhythm of the metronome
beat
Use of giant knitting needle to
practice tripod grasp onto trigger.
Goal #2
• Handwriting training
• Postural alignment and
strengthening
• Sensory integration training
• Visual-motor training
• Reflex integration training
• Gross and fine motor skills
training
Use of office footrest as a slant
board to increase anterior
pelvic tilt and postural control
Suspended hand trigger
placement working on grasp/
release and visual control
Goal #3
• Use of hoop to address boundary for movement with
overhand reach
• Use of large/novel items to reinforce modified tripod grip
• Visual motor applications during IM
• Balance applications during IM
Use of hoop to define Motor plan
for overhand throw
Tracing infinity loop with trigger
placed at center to mark the
beat
Goal #4
• Use of child-specific interest (i.e., sports)
• Use of turn-taking games to increase attention to
task
• Allow child to set up components of the activity
Overhead swing with bat to
trigger, within the context of sport,
to increase motivation to
challenge
Turn taking to increase focused
attention to task
Reference Point
Calming down after IM session
• Now, for your own reference, jot down 3 sample
goals that you may have for an individual using IM.
• Consider how IM can fit in with “the whole picture”
when planning discipline specific treatment.
Infinity Loop with IM
The Ultimate Balance
Challenge
Going Backward to Come
Forwards
Assessing the Right Pace
• Strategies to customize your approach with the
pacing of IM activities include:
- Adjusting the tempo
- Adjusting the duration of IM tasks
- Adjusting the frequency of IM tasks
- Supplementing IM tasks with age-appropriate
incentives
- Monitoring IM participant for signs of distress
or fatigue
Signs of
Distress/Fatigue/Overload
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Oral motor overflow
Sweating
Changes in skin color
Marked increases/decreases in postural control
Aversion to sensory input
Increases in motoric output
Changes in respiratory rates
Increased fidgeting behaviors
Increased vocal distress
Increased verbal distress
Decreased attention/engagement
IM Activity with Comfort
Accommodations
IM Activities with Graded Force
Pressure Accommodations
Riley Completing Step-up with IM
Riley Completing Upper Body Visual
Challenge During Step IM Routine
Child Led challenge with IM-HOME
Motivational Strategies
Challenges
• FACT: Most children do not
inherently want to work.
• FACT: Most children do not
like to be told what to do.
• FACT: Most children have
short attention spans.
• FACT: Most children do not
like to engage in “nonpreferred” activities.
Motivational Strategies
Assets
• FACT: Most children want to have fun.
• FACT: Most children enjoy novel activities.
• FACT: Most children seek approval and success.
• FACT: Most children enjoy variety as well as routine.
Treatment Planning
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What are their likes/dislikes?
What are their “quirks”?
What is their “speed”?
What are their parameters to
sensory/motor/behavioral triggers?
• How well do they respond to change?
Strategies to Motivate
Children During IM
• Ask them!
• Outline/structure
• Pre/post IM activities
to arouse/calm
• “Guesstimating”
scores
• Reward incentives.
• Parent/caregiver
involvement
Pre-IM Activities
Vestibular: Facilitate a ‘ready-alert-state’
through movement.
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Access
Specific training re vestibular input to cns output
Reward incentive
CAUTION you need to be
in control/set parameters
Pre-IM Activities
Balance activities: to
increase focus
• Smaller base of
support
• Unstable surface
• Alert CNS
• Activate major
muscle groups
Pre-IM Activities
Visual-motor: Alert balance, muscle
energy and hand-eye coordination
skills.
• Rolling a ball in sequence on a tray
• Tapping a suspended ball with index
finger
• Hitting a suspended ball with a bat
• Tapping a suspended balloon
• Rolling marbles into targets
Popcorn & IM in the Great
Outdoors After Dark…
Increased Focus & Attention
with Novel Play
Combined Preferred Activities
with IM
Hitting Foot Trigger with
Baseball Bat
Bribery & Distraction
Equipment to Enhance
Pediatric Performance
Useful Equipment
to Have ‘In Your Box’
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Velcro
Multiple Triggers
Specialized Triggers
Colored Tape
Weighted tape
Fidget items
‘Quick fix’ items
Reinforcement items
Age-appropriate toys
and games
On the Stool & On the Beat
Busy Fingers
Animated Speakers
Age Considerations
“At what age can I
effectively
introduce
Interactive
Metronome
activities into my
treatment
programs?”
My inspiration…Emma….
A presentation at the IM Professional Conference 2007
My thanks to Lucy Barlow, MED. SLP-CCC
From The Language Learning Center, Kingsland, Georgia.
Why IM for Emma?
• This provider’s prior observations of the
success of IM with cross-hemisphere
difficulties
• Neuro-rehabilitative aspects of IM
• Prospect of stimulating hemispheric
communications
• Motivation to achieve best possible
outcome for patient
IM Modifications with Emma &
Lucy Barlow (SLP)
Emma…A Mother’s Story
Reyna
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18 month year old
Feeding disorder in infancy
Sensory integration issues
Taste – texture –
temperature variances
Spitting up – gagging vomiting during meals
Extensor posturing
Breath holding
Decreased oral exploration
and play skills
Speech delays
Clapping to Music
Using Video Feedback
Wonderful Reyna
Lab 1 - Addressing Use of IM with Low
Level Clients, Infants & Young Children
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Demonstrate 3 whole body movement techniques suitable for this
client group.
1. ____________________________________
2. ____________________________________
3. ____________________________________
Consider environmental barriers that may hinder IM success with
this client group.
1. ____________________________________
2. ____________________________________
3. ____________________________________
Practice 3 modifications in positioning for this client group.
1. ____________________________________
2. ____________________________________
3. ____________________________________
Lab 1 - Addressing Use of IM with Low
Level Clients, Infants & Young Children
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Practice using 3 modifications to switches for this client group.
1. _____________________________________________
2. _____________________________________________
3. _____________________________________________
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Incorporate 3 motivational activities to engage attention for this
client group.
1. _____________________________________________
2. _____________________________________________
3. _____________________________________________
Lab 2 – Addressing the Use of IM in a
Group Setting
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Practice turn-taking with IM involving 3 or more group members.
Set up an activity circuit using IM as a component task.
List 3 benefits of using a group IM setting.
1. ____________________________________
2. ____________________________________
3. ____________________________________
What additional equipment do you need in order to complete group
IM?
1. ____________________________________
2. ____________________________________
3. ____________________________________
Lab 3 – Incorporating IM into Your
Discipline Specific Functional Goals
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List 3 goals that you may typically work on with the pediatric
population.
1. _____________________________________________
2. _____________________________________________
3. _____________________________________________
Review the benefit of IM use in achieving those goals.
1. _____________________________________________
2. _____________________________________________
3. _____________________________________________
List 3 custom IM activities for each goal.
1. _____________________________________________
2. _____________________________________________
3. _____________________________________________
Marketing IM with the
Pediatric Population
1) Budget….
2) Target group
3) Treatment setting
4) Payment sources
5) Referral sources
6) Advertising
7) Local competitors?
8) Prepared information
9) Intake process
10) Budget …..
Communicating with Other
Healthcare Professionals
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By example
By results
Literature
In-services
Peer review/case
studies
Communicating with the
General Public
• Community sources
articles/advertising
• News-media interviews
• Word-of-mouth
• Literature flyers
• Free IM screening
• Parent-friendly inservices
Communicating with a
School Team
• Assess school routines, teaching
style and student need
• Teacher in servicing classes
• Use of empirical data,
academically relevant case studies
to tune in with each teacher’s
perception of need
• Lead by example – impact by
performance
• Market also to grant writers and
parent-teacher organizations to
raise funds for IM programming
Workshop
Consider the following areas as they apply to your practice and
try to give one example of each:
1. Whole body movement with IM
___________________________________________________________
2. Deep pressure play with IM
___________________________________________________________
3. Music with IM
___________________________________________________________
4. Adaptations for positioning with IM
___________________________________________________________
Workshop
Consider the following areas as they apply to your practice and
try to give one example of each:
5. IM to increase auditory attention
___________________________________________________________
6. Sensory-tactile interventions with IM
___________________________________________________________
7. Role playing with IM
___________________________________________________________
8. Fine motor coordination with IM
___________________________________________________________
9. Core strengthening exercises with IM
___________________________________________________________
Workshop Sample Answers
1. Whole body movement with IM
– Firm pressure through child’s shoulders
– Rolling side to side in a sheet
– Rocking child back and forth in your lap
Workshop Sample Answers
2. Deep pressure play with IM
– Use of resistive band to access triggers
– Use of weighted blankets during IM activities
– Having child lie under a mat or
cushions/beanbag during activities
Workshop Sample Answers
3. Music with IM
– Strap jingle bells to moving extremity (i.e., arm
or leg, during clapping/stamping activities)
– Shaking maracas/beating a drum to the tempo
beat
– Dancing from foot trigger to foot trigger during
paced rhythmical music
Workshop Sample Answers
4. Adaptations for positioning with IM
– Holding child on your lap
– Sitting in a beanbag
– ‘Hiding’ under a table
Workshop Sample Answers
5. IM to increase auditory attention
– Turn taking on the beat
– Turn taking to different repetitions (i.e., you hit
5 times, another child hits 3 times, I will hit 1
time)
– Answering questions of increasing difficulty
during IM (i.e., What did you have for breakfast
this morning?)
Workshop Sample Answers
6. Sensory – tactile interventions with IM
– Use of speakers in place of headphones
– Use of soft gloves when clapping to dampen
touch stimuli
– Use of a toy to manipulate the trigger (i.e., a
soft play hammer)
Workshop Sample Answers
7. Role-playing with IM
– Sitting in a tub ‘boat’ and rowing by slapping
trigger hand against the side
– Pretending to be a fairy princess waving her
wand and ‘tapping’ a giant pumpkin
– You be the IM teacher then I will be the IM
teacher…what shall we do?
Workshop Sample Answers
8. Fine motor coordination exercises with IM
– Isolated digit tapping onto hand trigger, with use
of finger puppets
– Holding manipulative with specific grip and
tapping hand trigger
– Squeezing hand onto hand or foot trigger to
strengthen grip
Workshop Sample Answers
9. Core strengthening exercises with IM
– IM sitting on ball
– IM sitting on t-stool
– Reaching overhead and towards feet
sequentially to hit trigger targets
Review
Are we there yet?
Exam
We know you’re tired…but…da-da-dahhhh
Exam Review
1. What is the recommended time-frame for
IM interventions with a pediatric client?
a.
b.
c.
d.
2 weeks
15 weeks
2-15 weeks
It varies, dependent upon the individual
treatment plan.
Answer: d
Exam Review
2. True or False : An infant of 18 months is
too young to participate in a modified IM
program.
a. True
b. False
Answer: b
Exam Review
3. What signs would indicate distress during
IM activities?
a. oral-motor overflow, focused attention,
sweating, breath-holding
b. increased fidgeting, sweating, pacing,
improved articulation
c. oral-motor overflow, sweating, decreased
attention, increased verbal agitation
d. increased fidgeting, decreased attention,
improved breath control, skin pallor
Answer: c
Exam Review
4. True or False: You may introduce IM tasks
gradually, then build up a routine so that
the child comes to expect IM as part of
their session - just as they would any
other of your discipline-specific activities.
a. True
b. False
Answer: a
Exam Review
5. True or False: Group treatments may be
used for all IM students.
a. True
b. False
Answer: b
Exam Review
6. The following may be used as motivational
strategies with the pediatric population:
a.
b.
c.
d.
verbal praise; stickers; preferred activities
bubbles; high five; rest breaks
turn taking; edible treats; control choices
all of the above
Answer: d
Exam Review
7. The following are good choices to help
calm a student:
a.
b.
c.
d.
decreased volume
a large work space
light pressure during activities
bright lighting
Answer: a
Exam Review
8. True or False: Multiple triggers can be a
useful tool for IM modifications: True or
False?
a. True
b. False
Answer: a
Exam Review
9. Which of the following can you incorporate
into your IM sessions?
a.
b.
c.
d.
music
whole body movements/rhythm experiences
auditory processing games
all of the above
Answer: d
Exam Review
10. Adding specialized (pediatric) IM
programs to your practice can offer you:
a.
b.
c.
d.
increased referral base
teaching opportunities
career development
all of the above
Answer: d
Q&A